Hospital league tables, targets, and performance incentives should be used with care

Abstract

Richard Lilford and colleagues argue that the UK government’s plans to use performance metrics to reward or punish hospitals risk doing more harm than good Healthcare consumes a lot of resources and various measures have been used to try to ensure they are used efficiently. In the UK, after the government increased investment in health services, the secretary of state for health and social care announced that “NHS England will carry out a review of NHS performance across England with the results made public in league tables”1 and threatened that managers would be sacked if they don’t improve hospital performance.2 The health secretary is advocating using a performance metric that evaluates an organisation as a whole. The use of this type of metric to improve healthcare is neither new nor unique; policy makers often turn to performance management in the form of incentives based on organisation-wide targets or league tables. For example, in the US the Leapfrog group generates a “single letter grade representing a hospital’s overall performance” for nearly 3000 general acute care hospitals,3 and the Centers for Medicare and Medicaid Services measures whole hospital performance using a much criticised star rating system.4 With the announcement of the abolition of NHS England in March 2025, the government clearly intends to take direct control of the NHS and influence NHS organisations through performance metrics coupled with incentives and sanctions. This makes it important to consider the evidence on their accuracy and whether they have their intended effect. The quality of a measurement is defined by its reliability and validity. An unreliable measure has a low ratio between the signal (the true differences between the objects of measurement) and noise (all other sources of variation in a measurement).56 Low reliability results in misclassification of hospitals. …